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Update December 2016


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Update by Natrakorn Paewsoongnern
 
 
 

Doctor's Consultation  by Dr. Iain Corness

 

Update December 30, 2016

A PET scan is not an X-Ray of your dog

There is only December 30 and 31 left in which to pay to get the discounted Check-up Packages in my hospital. However, as long as you have paid before December 31, you have till February 28 to actually have the physical examination.

The usual request is “I want everything.” And by that they mean blood testing. If I told them that sitting on my desk is the “Manual of Use and Interpretation of Pathology Tests” which is almost 400 pages and there are about five tests per page. Imagine the bill for all that lot! But I doubt if many of you need Basement Membrane Antibodies to be done for any reason.

There is also, in the collective subconscious, interest in a “whole body scan” which is thought of as some magical device that you can walk into in one end and out the other and a print-out will tell you (and us) exactly how you are inside and out. Every organ! Even Willy the Wonder Wand! Unfortunately, this is stretching the truth somewhat. Machines like that are only seen in Star Trek movies.

However, there is the PET scan, which is a specialized form of whole body scanner, that can give an indication of what is going on inside.

PET stands for Positron Emission Tomography and is a type of nuclear medicine imaging. Nuclear medicine is a subspecialty within the field of radiology that uses very small amounts of radioactive material to diagnose or treat disease and other abnormalities within the body.

Nuclear medicine imaging procedures are noninvasive and usually painless medical tests that help physicians diagnose medical conditions. To be able to produce the images in a PET scan, you have to have radioactive materials, called a radiopharmaceutical or radiotracer, and these are injected into your veins. The radioactive material has a very short life and is usable for only about two hours, though it will take a day before you have excreted it all.

The radioactive energy is detected by a device called a gamma camera, a (positron emission tomography) PET scanner. These radiology devices work together with a computer to measure the amount of radiotracer absorbed by your body and to produce special pictures offering details on both the structure and function of organs and other internal body parts.

The PET scanner is most usually used in cancer medicine and can demonstrate a ‘hot spot’ to show up the primary cancer, stage a cancer, show any metastases (spread), and even show whether cancer treatment modalities are working. For example, the PET scan can show the difference between scar tissue and active cancer tissue.

The benefits provided by PET scans are primarily because the information provided by nuclear medicine examinations is unique and often unattainable using other imaging procedures.

For many diseases, nuclear medicine scans yield the most useful information needed to make a diagnosis or to determine appropriate treatment, if any.

Nuclear medicine is much less traumatic than exploratory surgery.

By identifying changes in the body at the cellular level, PET imaging may detect the early onset of disease before it is evident on other imaging tests such as CT or MRI.

The risks are very low. Because the doses of radiotracer administered are small, diagnostic nuclear medicine procedures result in minimal radiation exposure. Thus, the radiation risk is very low compared with the potential benefits.

Nuclear medicine has been used for more than five decades, and there are no known long-term adverse effects from such low-dose exposure.

Allergic reactions to radiopharmaceuticals may occur but are extremely rare.

Injection of the radiotracer may cause slight pain and redness which should rapidly resolve.

Women should always inform their physician or radiology technologist if there is any possibility that they are pregnant or if they are breastfeeding their baby.

Can you get this kind of scan here? Yes, at Wattanosoth Hospital in Bangkok, and it costs around 60,000 baht last time I asked. However, if you purchase a Chivawattana personal health insurance card (available at Bangkok Hospital Pattaya) it has a discount for the PET scan (as well as many other benefits). Well worthwhile looking into if a PET is on the agenda.


Update December 24, 2016

Christmas Disease – it’s not Happy Holiday disease!

Christmas Disease has nothing to do with Happy Holidays, Christianity, or Santa, mangers, three wise men and a bottle of myrrh. But it has everything to do with Stephen. And not St. Stephen but Stephen Christmas, that is.

Stephen, a young British lad, was the first patient with a bleeding tendency recognized to have a different form from “classical” hemophilia (or haemophilia if you come from the right hand side of the Atlantic Ocean).

His condition was studied by researchers Biggs, Douglas, and Macfarlane in 1952, who discovered that young Stephen was missing a different coagulation factor than the more usual one (which is known as Factor VIII). They named Stephen’s missing factor as Factor IX, and his condition became known as Christmas Disease.

Just to confuse the issue, we also call Christmas Disease by other names, including Factor IX deficiency, hemophilia II, hemophilia B, hemophiloid state C, hereditary plasma thromboplastin component deficiency, plasma thromboplastin component deficiency, and plasma thromboplastin factor-B deficiency. There’s probably more, but Christmas Disease has a much nicer “ring” to it. (Probably “Jingle Bells” at this time of year!)

From the diagnostic viewpoint, it is very difficult to differentiate between classical hemophilia (my editor comes from the left hand side of the Atlantic, so it is spelled with “e”) and Christmas Disease. The symptoms are the same, with excessive bleeding seen by recurrent nosebleeds, bruising, spontaneous bleeding, bleeding into joints and associated pain and swelling, gastrointestinal tract and urinary tract hemorrhage producing blood in the urine or stool, prolonged bleeding from cuts, tooth extraction, and surgery and excessive bleeding following circumcision.

Christmas Disease covers around one in seven cases of the total hemophilia incidence and is around 1/30,000 in the general population. This disease is also male dominated, being called a sex-linked recessive trait passed on by female carriers. This means the bleeding disorder is carried on the X chromosome. Males being of XY make-up will have the disease if the X they inherit has the gene. Females, who have XX chromosomes, are only carriers if either X has the bleeding gene.

Hemophilia has been noted in history for many years, and Jewish texts of the second century A.D. refer to boys who bled to death after circumcision, and the Arab physician Albucasis (1013-1106) also described males in one family dying after minor injuries.

In more recent history, royal watchers know that Queen Victoria of Britain’s son Leopold had hemophilia, and that two of her daughters, Alice and Beatrice, were carriers of the gene. Through them, hemophilia was passed to the royal families in Spain and Russia, leading to one of the most famous young men with the disease, Tsar Nicholas II’s only son Alexei.

In the 1800’s physicians thought that the bleeding occurred because of a structural problem in blood vessels. In 1937 a substance was found in normal blood that would make hemophilic blood clot, which was named “anti-hemophilic globulin.”

In 1944 researchers found in one case that when the blood from two different hemophiliacs was mixed, both were able to clot. Nobody could explain this until 1952, when the researchers in England realized there were two types of hemophilia. They called his version hemophilia B, or “Christmas disease,” and the more prevalent kind hemophilia A, or “classic hemophilia.”

With the discovery of A and B types came the realization that there must be different types of “anti-hemophilic globulin” involved in the clotting process. Names were assigned to these various “coagulation factors” by an international committee in 1962. Hemophilia A is a deficiency of Factor VIII, and hemophilia B is a deficiency of Factor IX.

Once it became clear that hemophilia was caused by a deficiency of a coagulation factor, replacement of the missing factor became the method of treatment. In the early 1950’s animal plasma was used. By the 1970’s, coagulation factor concentrates made from human plasma were available, and by the 1980’s we could guarantee that it was HIV free. It has been a long road since Stephen Christmas.

Last minute reminder!

The discount check-up packages at Bangkok Hospital Pattaya have to be paid for by December 31, but you can delay having the test up till 28 February 2017.


Update December 17, 2016

Where’s my readers?

I don’t need these any more!

By “readers” I don’t mean those kind souls who read my columns, but I am referring to reading glasses. I just opened my top drawer at work and there were eight pairs of readers! No, it wasn’t a “Buy 1 and get 7 free!” These were the result of wear and tear, broken side pieces, lenses missing, broken frames, unsuccessful repairs with Super Glue or Araldite (the Greek Goddess of stickiness) and the list goes on. I did, however, manage to successfully glue my finger to one lens with Super Glue. It did neither the lens, or my finger, any good at all.

A little history here, which will probably remind you of your time of decreasing visual acuity.

26 years ago I was ready to admit that my near vision was gone. Reading a map was just not possible, even holding the map in front of the headlights. A visit to the optometrist saw me leaving with suitable contact lenses which introduced a whole new world to my life. I could read the destination signs on busses and street signs ditto.

Unfortunately this Utopia was not to last. Stronger prescriptions for the contact lenses did help, but were not the answer. Remembering to remove the contacts every night was a bit hit and miss, but I always knew in the morning as the lenses were stuck to my eyeballs and everything was blurred.

I did try and remember to use a sterile technique putting the lenses in, but that too would fail regularly and I would have to do without, which suggested to me that a white stick and a Labrador was next. Of course there were also the dropped lenses with me on all fours looking for the errant bit of soft plastic.

I struggled on, but then found that my distance vision was not as good as it used to be. Recognizing faces across the street was difficult. By now I had arrived at a situation where driving at night was taking my life in my hands.

It was at this point that I discussed my vision with Dr. Somchai Trakool Choke-satian in the SuperSight surgery department at the Bangkok Hospital Pattaya.

It was at that initial consultation that I discovered that SuperSight was not just changing the lens in the eye, but a thorough eye examination to ensure that the eye itself is healthy, other than the cataracts and hardening of the natural lens. This examination takes about one hour, so it’s not a case of “Read the bottom line,” and it’s all over style exam.

Dr Somchai advised me that my eyes were suitable for the SuperSight lenses and then went on to discuss all the pros and cons of the surgery and the final results that could be expected, and then told me to go and think about it.

I did that by speaking to all the people I knew who had SuperSight surgery done before. To a man the answers were the same, “Wish I’d done it years ago”.

So a convenient date was selected for Dr. Somchai and myself and the stage was set. No turning back.

I am asked by others whether the operation was painful and I can honestly say it was not. It is a weird sensation having someone ‘inside’ your eyeball, but not painful. Under local anesthetic I found I could relax and keep my eye still as Dr. Somchai did his magic. And the results are magical. And the freedom from the glasses is wonderful.

Now two months after the operation, I still pat my pocket for the readers as I sit down in front of the computer and then realize I don’t need them. And as a funny ending, I can now wear T-shirts without a pocket for the glasses. My wardrobe has doubled! And I can finally read the numbers on the remote for the TV.

For more information contact the SuperSight surgery department at the hospital, they are nice people. Telephone 1719.


Update December 10, 2016

Do you have “sugar”

Diabetes is a serious ailment, which can arise for many reasons, and can affect many systems in the human body. Diabetes, often called “sugar” by patients, is diagnosed and monitored mainly through a simple blood test – the Blood Glucose level.

Glucose is a type of sugar found in fruits and many other foods (this includes lactose and fructose). It is the main source of energy used by the body. Most of the carbohydrates that people eat are also turned into glucose, which can be used for energy or stored in the liver and kidneys as glycogen.

To stop the sugar levels just increasing daily, a balance is achieved through a hormone called Insulin which helps the body use and control the amount of glucose in the blood. Insulin is produced in areas of the pancreas called ‘islets’ and released into the blood when the level of glucose in the blood rises. In simple terms, people who do not produce enough insulin develop diabetes. People can also develop diabetes if they do not respond normally to the insulin their bodies produce. This occurs most commonly when a person is overweight, and since obesity is on the rise, so are various types of diabetes.

Normally, blood glucose levels increase slightly after a person eats a meal. This increase causes the pancreas to release insulin so that blood glucose levels do not get too high. Blood glucose levels that remain high over time can cause damage to the eyes, kidneys, nerves, and blood vessels, which explains why good glucose control is important.

There are many ways to carry out blood glucose tests, including fasting blood sugar (FBS). This is a measurement of blood glucose after fasting for 12 to 14 hours. For an accurate fasting blood sugar test, do not eat or drink for 12 to 14 hours before the blood sample is taken. However, water can be freely taken, as otherwise hemoconcentration occurs to give a falsely high reading. This is often the first test done to detect diabetes, and explains why fasting blood tests are usually done when having a medical check-up.

The other common test is called the random blood sugar (RBS). A random blood sugar measurement may also be called a casual blood glucose test. This is a measurement of blood glucose that is taken regardless of when the person last ate a meal. Sometimes several random measurements are taken throughout a day. Random testing is useful because glucose levels in healthy people do not vary widely throughout the day, so wild swings may indicate a metabolic problem.

Glucose tolerance testing can also be done, usually to confirm a condition known as gestational diabetes, which can occur during pregnancy. An oral glucose tolerance test is simply a series of blood glucose measurements taken after a person drinks a liquid containing a specific amount of glucose; however, this test is not used to diagnose diabetes.

To monitor the treatment of diabetes, there are another couple of tests which can be carried out. The commonest is Glycated Hemoglobin, otherwise referred to as HbA1c. This test actually is an indicator of the average glucose concentration over the life of the red blood cells (which is taken as over the previous three months).

Another is the Serum C-Peptide which is used to investigate low blood sugar levels, done by measuring the C-Peptide which is produced by the Beta cells in the pancreas.

“Normal” levels may vary from lab to lab, but generally the range taken for FBS is that the level should be less than 110 milligrams per deciliter (mg/dL).

Diagnosis of diabetes needs a fasting blood glucose level higher than 125 mg/dL on two separate days.

A fasting glucose level below 40 mg/dL in women or below 50 mg/dL in men that is accompanied by symptoms of hypoglycemia (low blood sugar) may indicate an insulinoma, a tumor that produces abnormally high amounts of insulin. Lower than expected glucose levels can also indicate Addison’s disease, an underactive thyroid gland or pituitary gland, liver disease (such as cirrhosis), malnutrition, or a problem that prevents the intestines from absorbing the nutrients in food.

So you can see “sugar” is important which is why we have specialist endocrinologists at my hospital.


Update December 3, 2016

Bernardino Ramazzini where are you now?

Bernardino Ramazzini (1633 – 1714) was an Italian physician who is considered to be the founding father a rather different medical specialty called Occupational Medicine. One of the lesser known medical specialties, this is the study of worker health, how the workplace affects health, the man-machine interface, industrial exposure to contaminants and many other occupational hazards. (This is not something very well known in SE Asia.)

There are many medical conditions caused by work, right the way from Housemaid’s Knee and another example of occupationally induced conditions is ‘Vibration White Fingers’ and comes under the general umbrella of an interesting set of conditions known as Raynaud’s phenomenon.

Since doctors like to have conditions named after them, Raynaud’s phenomenon comes from Dr. Maurice Raynaud, a French physician who published a report in 1862 of a young woman whose fingertips changed colors when she was cold or under stress. He is credited with the discovery of the condition.

Raynaud’s phenomenon, sometimes called Raynaud’s syndrome or disease, is a disorder of blood circulation in the fingers. This condition is usually produced by exposure to cold which reduces blood circulation causing the fingers to become pale, waxy-white or purple. This condition is sometimes called “white finger,” “wax finger” or “dead finger”. These attacks occur when the hands or the whole body get cold either at work or at home. Household or leisure activities resulting in cold exposure can include washing a car, holding a cold steering wheel, or the cold handlebars of a bicycle. Attacks of white finger can also occur when a person is outdoors watching sports, or while gardening, fishing or golfing in cold weather.

Typical attacks occur with tingling and slight loss of feeling or numbness in the fingers, blanching or whitening of the fingers, usually without affecting the thumb, and pain, sometimes with redness, which accompanies the return of blood circulation generally after 30 minutes to two hours.

Many cases of Raynaud’s phenomenon are such that we cannot identify the cause. To escape the embarrassment of admitting that we just don’t know, we call this “primary Raynaud’s phenomenon” or even “constitutional” white finger. However, when we do know the occupational cause of Raynaud’s phenomenon we call it “secondary Raynaud’s phenomenon”!

In the occupational sphere, there are many causes of this secondary condition. It is most commonly associated with hand-arm vibration syndrome but it is also involved in other occupational diseases. Awareness of the condition can help prevent the disorder from occurring or progressing, as if not detected in the early stages, the disorder can permanently impair blood circulation in the fingers.

Although Raynaud’s phenomenon is not life threatening, severe cases cause disability and may force workers to leave their jobs and workman’s compensation issues may end up in courts of law. Although rare, severe cases can lead to breakdown of the skin and gangrene. Less severely affected workers sometimes have to change their social activities and work habits to avoid attacks of white finger.

The underlying cause relates to the physiology of maintaining an even body temperature. Usually, the body conserves heat by reducing blood circulation to the extremities, particularly the hands and feet. This response uses a complex system of nerves and muscles to control blood flow through the smallest blood vessels in the skin. In people with Raynaud’s phenomenon, this control system becomes too sensitive to cold and greatly reduces blood flow in the fingers.

Exposure to vibration from power tools is by far the greatest concern in secondary Raynauds. Hand-held power tools such as chain saws, jackhammers and pneumatic rock drillers and chippers can cause “hand-arm vibration syndrome”. This disorder is the “vibration white finger”, “hand-arm vibration syndrome (HAVS)”, or “secondary Raynaud’s phenomenon of occupational origin.” How many times have you seen Thai construction workers with the flip-flop “safety” footwear blasting away on concrete floors? Many times I am sure.

Another occupationally induced Raynaud’s phenomenon occurred in the early years, before the cancer-causing effects of vinyl chloride monomer were known. Workers exposed to high levels of this chemical also experienced Raynaud’s phenomenon.

So that is the story of Raynaud’s phenomenon. Fortunately, in our warm tropical climate it is not seen too often, other than the occupational secondary variety.


HEADLINES [click on headline to view story]

A PET scan is not an X-Ray of your dog

Christmas Disease – it’s not Happy Holiday disease!

Where’s my readers?

Do you have “sugar”

Bernardino Ramazzini where are you now?
 

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